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July 27, 2023

What are Never Events in Nursing & How to Help Avoid Them Using Immersive Virtual Reality

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Ginelle Testa
UbiSim Story Teller

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Never Events in nursing are serious, preventable errors or incidents that should never occur in healthcare. They result in severe harm or death and are considered avoidable. The AHRQ & National Quality Forum have a list consisting of 29 "serious reportable events" grouped into seven categories:

  1. Surgical or procedural events
  2. Product or device events
  3. Patient protection events
  4. Care management events
  5. Environmental events
  6. Radiologic events
  7. Criminal events

It goes without saying that virtual reality (VR) isn’t a fix-all for Never Events. Addressing and preventing them requires a comprehensive approach from all angles. However, here are some ways immersive VR can help. 

Ways Immersive VR Can Help Prevent Never Events in Nursing

1. Enhances situational awareness

VR simulations can recreate complex healthcare environments, enabling nurses and learners to experience and navigate various scenarios, such as a patient with pyelonephritis. By improving their situational awareness, they can better identify potential risks and take proactive measures to prevent Never Events.

With UbiSim, nurse educators and hospitals can customize scenarios with our intuitive Editor. There are ready-made scenarios, too, and scenarios created by other nurse educators and hospitals are shared within our Community. 

2. Facilitates team communication and coordination

Immersive VR can facilitate team-based training, enabling nurses to collaborate and communicate effectively in simulated healthcare settings. By practicing interprofessional teamwork, nurses can enhance their coordination and communication skills, crucial for preventing Never Events.

With UbiSim, nurses and nurse learners can peer-facilitate, helping them learn from one another. We also have a multiplayer mode where they can work together to help a virtual patient. 

3. Continuous learning and improvement

VR-based training can provide ongoing opportunities for nurses in hospitals to enhance their skills and knowledge related to patient safety. By engaging in regular VR simulations and debriefing sessions, nurses can identify areas for improvement and implement changes in their practice.

4. Error recognition and response

VR can simulate various patient conditions, presenting nurses with lifelike scenarios where errors or critical situations are intentionally introduced. This allows nurses to practice recognizing these errors promptly and responding appropriately, improving their ability to mitigate risks and prevent Never Events.

With UbiSim’s intuitive Editor, it is possible to create a "Room of Errors" where learners can perform a physical and environmental assessment and note the errors in the room. Some of these errors include:

  • A wrong name, DOB, or allergies on the wristband
  • Overflowing sharps box
  • Expired hand sanitizer
  • Wrong medications (amounts, concentrations, etc.) in the cart (learners need to call the pharmacy)
  • Inappropriate orders from the provider (learners can call the provider and clarify)
  • And lots more

Scenarios where UbiSim can help train in error prevention

Patient death or serious injury associated with unsafe administration of blood products

UbiSim has multiple scenarios that train nurse learners on blood administration and recognizing/responding to transfusion reactions. This is a skill that student nurses cannot practice in clinical placements because they must have a license to administer blood. 

Patient death or serious injury associated with a medication error

UbiSim scenarios allow learners to perform necessary dosage calculations and practice the five rights of medication administration. Our software captures if the learner verifies the name band and administers the correct dose/route/time/rate, etc.

Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

Learners receive real-time lab results that should be communicated to the provider via SBAR communication. Failure to communicate these critical results may lead to a patient's decline.

Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare setting

Using bedrails correctly is a fundamental skill that matters. Our bed rails in UbiSim are functional, and learners are able to identify whether having all four side rails up is appropriate or inappropriate in a given scenario. This is important because using all side rails up can be considered a restraint, and in some circumstances, patients who are experiencing confusion or other conditions can get seriously injured by trying to exit the bed.

Want to try UbiSim with your nurse learners to better prepare them for the Next Generation NCLEX (NGN) Exam and help them become more precise nurses? Get a quote today.
Interested in trying UbiSim in your healthcare institution?
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Ginelle Testa
UbiSim Story Teller

As an integral center of UbiSim's content team, Ginelle pens stories on the rapidly changing landscape of VR in nursing simulation. Ginelle is committed to elevating the voices of practicing nurses, nurse educators, and program leaders who are making a difference.

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